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2011_1219CHECK ONE. IRRIGATION DOlYIESTIC FIRELINE BACT�ZOW PREVENTION ASSEMBLYlY TEST AND MAIIVTEN)ANCE REPORT NAME OF PWS. �` 2t,J �EC.}i I� 1 Q h i O yp�—� f PWS I.D. #t % ./� r J LOCATION OF SERVICE: 113 �Q Y� t.i E? 1 S �7 1 U �l The bacictlow prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is cadfied to be operating within acceptable parameters. i� Reduced Pressure Principle o Double CLh�e�ck Valve Manufacttu�cr �Q� Model Number � r��I m-7 � Fx / Serial Number " T3 / TYPE OF ASSEMBLY o Pressure Vacuum Breaker O Atmosphere Vacuum Breaker Size � '�Z� Located At �u3r C- � aS-� �'? The above is certified to be true. Firm Name � � � --�- s• D. Certified Tester � fl v/ � � / I Firm Address / ��-� t'1 ,� Cert. Tester No. �� Date �°� �� �� Gauge # _ _ Z�J'� ©Q� Q Date last accuracy tested / � 3 % � White - Customer's Copy Yellow -City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BR��R Double Check Valve Assembly 1st Check 2nd Chekl: Relief Valve Air Inlet Check Valve Initial T_ est �� DC- Closed Tilt _ C7 Closed Tight o Lcal:cd � Opened at nsid Opined at � sid nsid 1� `,� �� RP- i nsid YYY���""" Leaked.. c Did not Opm 0 Leaked o Repairs � _ ? Lies -� `i� A�� n i� t�.T AwCr and Materials Used Test After DC- Closed Closed Tighe o Opened at Opined at � sid Repair Tight � RP sid <.7 nsid nsid The above is certified to be true. Firm Name � � � --�- s• D. Certified Tester � fl v/ � � / I Firm Address / ��-� t'1 ,� Cert. Tester No. �� Date �°� �� �� Gauge # _ _ Z�J'� ©Q� Q Date last accuracy tested / � 3 % � White - Customer's Copy Yellow -City Copy Pink - Tester's Copy